Monkeypox: Avoiding the Mistakes of Past Infectious Disease Epidemics
Authors: Demetre Daskalakis, R. Paul McClung, Leandro Mena, Jonathan Mermin, Jennifer McQuiston, Inger Damon, Benjamin Monroe, Laura Bachmann
Journal: Annals of Internal Medicine (2022)

Ideas and OpinionsAugust 2022Monkeypox: Avoiding the Mistakes of Past Infectious Disease EpidemicsFREEDemetre Daskalakis, MD, MPH, R. Paul McClung, MD, Leandro Mena, MD, MPH, and Jonathan Mermin, MD, MPH, for the Centers for Disease Control and Prevention's Monkeypox Response Team*Demetre Daskalakis, MD, MPHDivision of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (D.D., R.P.M.), R. Paul McClung, MDDivision of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (D.D., R.P.M.), Leandro Mena, MD, MPHDivision of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (L.M.), and Jonathan Mermin, MD, MPHNational Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (J.M.)., for the Centers for Disease Control and Prevention's Monkeypox Response Team*Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-1748 Annals Author Insight Video - Demetre Daskalakis, MD, MPH In this video, Demetre Daskalakis, MD, MPH, offers additional insight into the article, "Avoiding the Mistakes of Past Infectious Disease Epidemics." (Duration 3:38) SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Monkeypox virus, an orthopoxvirus related to the variola virus that causes smallpox, causes a zoonotic disease with an unknown animal reservoir. Clinical manifestations of monkeypox include a prodrome of fever, lymphadenopathy, headache, and malaise 1 to 2 weeks after infection, progressing to a centrifugal rash that includes vesicles and pustules, sometimes numbering in the hundreds or thousands (1). Monkeypox virus infection can be transmitted through cutaneous routes during close or intimate contact with a person whose lesions are not yet crusted over and healed, via fomites that have had contact with a person with monkeypox, and by respiratory droplets among people with close, sustained face-to-face contact.Monkeypox is endemic to parts of Africa and most recently reemerged in Nigeria in 2017. Beginning in May 2022, several countries without endemic monkeypox have reported cases, including the United States. To date, most but not all of the cases outside endemic countries in this recent outbreak have been reported in gay, bisexual, and other men who have sex with men (MSM). In the cases occurring in 2022, the disease presentation has included atypical features, such as lesions isolated to the genital and anal regions and minimal prodromal symptoms (2).Accurate description of the epidemiology of an infectious disease is essential to public health efforts. Careful epidemiology helps to increase awareness and use of preventive measures while also avoiding the stigma and discrimination that can occur when conditions are more frequent in specific communities. The epidemiology of an emerging infection may change over time, but early associations with a specific population made by the public, clinicians, and health agencies often persist. This may result in stigma and misguided confidence that an outbreak is contained within that population. The original misnomer for HIV—gay-related immune deficiency (GRID)—looms large in the consciousness of many gay men and offers a cautionary lesson for monkeypox and other infectious disease outbreaks.Although the details of how monkeypox reached nonendemic countries during the current outbreak remain unclear, it seems to be disproportionately occurring in social networks of MSM (2). There is no known biological trait of monkeypox virus that increases its proclivity to infect MSM. Anyone can contract or spread monkeypox via close physical contact with lesions; through fomites, such as contaminated clothes and other objects; and through respiratory droplets.So why gay, bisexual, and other MSM? Multiple outbreaks have taught us that infectious diseases occur at different rates because of social, economic, and environmental factors, not biological ones. Pathogens do not intentionally discriminate on the basis of identity, such as race, gender, or sexual orientation—societies do—and monkeypox is no different. There are several potential reasons the current outbreak is to date concentrated among MSM. One is that all outbreaks begin somewhere. They enter social networks and propagate based on characteristics of the pathogen, the host, and the way people in the initial affected network live, work, travel, or play. However, infections seldom stay within these original populations, and there are rarely any biological reasons they would.To an extent, the current monkeypox outbreak is reminiscent of the rhetoric around the initial emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Many early cases of CA-MRSA were identified in MSM, leading to questions and assumptions about the role of sexual behavior in the outbreak. It was not long before CA-MRSA infections were also noted in other communities that may engage in close physical contact, including athletes and people living in congregate settings. We hope that the international public health response to monkeypox will rapidly end the outbreak for the health of all communities. If community transmission continues, many other communities in the United States and other nonendemic countries have the potential to be affected.Another reason that monkeypox might be disproportionately diagnosed among gay, bisexual, and other MSM could be related to ascertainment bias. Because many of the initial cases were diagnosed in MSM, sexual health providers and the MSM populations that they serve became particularly attentive to monkeypox and its clinical presentation. This initial vigilance might have increased the chance that cases among MSM would be diagnosed compared with other populations where clinician and patient awareness is not as high. Increasing awareness of monkeypox among all clinical providers and ensuring the availability of diagnostic testing could prevent missed opportunities to diagnose monkeypox and prevent transmission in all populations.The relationship between gay and bisexual men and public health is one that has been forged through the experience of the HIV and sexually transmitted infection epidemics. Most recently, an outbreak of the SARS-CoV-2 Delta variant associated with travel to a popular gay resort in Massachusetts demonstrated the willingness of many gay, bisexual, and other MSM to engage with public health and highlighted the intense interest of the community in its own health (3). Communicating a health risk in a way that is understandable and culturally appropriate for this population, including the use of trusted messengers and platforms, is an essential part of empowering people to make decisions that help them better protect their personal health and the health of their community.Focusing exclusively on one population when an infection is emerging can propagate stigma and prematurely narrow appropriate public health response. Narrow focus threatens the health of other communities that might also have a higher risk for being affected. Experience has shown the dangers of characterizing a disease by associating it with a single population or a particular identity. Such associations can create stigma that outlives the outbreak and lost opportunities to detect and address the infection in other populations. Knowledge is power. It is the responsibility of public health entities to alert communities to threats that may adversely affect their health, even when the epidemiologic data are still evolving. It is also critical that these efforts to end infectious disease outbreaks avoid the propagation of bias in communities that are already disproportionately affected by poor health outcomes.Appendix: Centers for Disease Control and Prevention's Monkeypox Response TeamMembers of the Centers for Disease Control and Prevention's Monkeypox Response Team are Jennifer McQuiston, DVM (Division of High-Consequence Pathogens and Pathology); Inger Damon, MD, PhD (Division of High-Consequence Pathogens and Pathology); Benjamin Monroe, CoS (Division of High-Consequence Pathogens and Pathology); and Laura Bachmann, MD, MPH (Division of STD Prevention). These people contributed to the article but did not author it.References1. McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014;58:260-7. [PMID: 24158414] doi:10.1093/cid/cit703 CrossrefMedlineGoogle Scholar2. Minhaj FS, Ogale YP, Whitehill F, et al; Monkeypox Response Team 2022. Monkeypox outbreak—nine states, May 2022. MMWR Morb Mortal Wkly Rep. 2022;71:764-9. [PMID: 35679181] doi:10.15585/mmwr.mm7123e1 CrossrefMedlineGoogle Scholar3. Brown CM, Vostok J, Johnson H, et al. Outbreak of SARS-CoV-2 infections, including COVID-19 vaccine breakthrough infections, associated with large public gatherings—Barnstable County, Massachusetts, July 2021. MMWR Morb Mortal Wkly Rep. 2021;70:1059-62. [PMID: 34351882] doi:10.15585/mmwr.mm7031e2 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Rujittika Mungmunpuntipantip (1), Viroj Wiwanitkit (2)(1)Private Academic Consultant, Bangkok, Thailand, (2)Joseph Ayobaalola University, Dr DY Patil University, University of Nis, Suranaree University of Technology21 June 2022 Correspondence on International Monkeypox Outbreak We would like to share ideas on the publication "Monkeypox: Avoiding the Mistakes of Past Infectious Disease Epidemics [1]" Although the specifics of how monkeypox entered nonendemic nations during the present outbreak are still unknown, Daskalakis et al. reported that it appears to be predominately occuring through social networks of MSM [1]. Increased clinical provider awareness of monkeypox and the availability of diagnostic tests, according to Daskalakis et al., could prevent missed opportunities to identify monkeypox and stop transmission in all groups [1]. Lessons from COVID-19, which showed us that we might react slowly to a situation, may have prompted us to act quickly to manage the monkeypox outbreak [2]. In fact, it is being thought about whether monkeypox could be transmitted from person to person [2]. As the number of cases reported in various nations rises, the medical community is alarmed, and meticulous planning is needed to prepare for a potential major outbreak. To conduct a thorough investigation and establish crucial procedures, we must act quickly and decisively [3]. Diagnostic tools are necessary, as Daskalakis et al. properly noted. It should also be mentioned that the diagnostic tool needs to be under quality control in addition to being available. The non-standardized diagnostic laboratory is not unusual, according to the earlier research [4]. Finally, it should be able to detect abnormal clinical illness presentation. If there is no recognition, the diagnosis may be delayed in cases that appear with an unusual clinical presentation, such as diarrhea, without a fever or skin rash [5]. References Daskalakis D, McClung RP, Mena L, Mermin J; Centers for Disease Control and Prevention's Monkeypox Response Team*. Monkeypox: Avoiding the Mistakes of Past Infectious Disease Epidemics. Ann Intern Med. 2022 Jun 16. doi: 10.7326/M22-1748. Online ahead of print. Wiwanitkit S, Wiwanitkit V. Atypical zoonotic pox: Acute merging illness that can be easily forgotten. J Acute Dis 2018;7:88-9 Mungmunpuntipantip V, Wiwanitkit V. Re-emerging monkeypox: an old disease to be monitored. BMJ Rapid Response Accessible online at https://www.bmj.com/content/377/bmj.o1239/rr-1 Accessed on 21 May 2022 Niedrig M, Meyer H, Panning M, Drosten C. Follow-up on diagnostic proficiency of laboratories equipped to perform orthopoxvirus detection and quantification by PCR: the second international external quality assurance study. J Clin Microbiol . 2006 Apr;44(4):1283-7. Mungmunpuntipantip R, Wiwanitkit V. Diarrhea and monkeypox: a consideration. Rev Esp Enferm Dig. 2022 Jun 15. doi: 10.17235/reed.2022.8957/2022. Online ahead of print. Author, Article, and Disclosure InformationAffiliations: Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (D.D., R.P.M.)Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (L.M.)National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (J.M.).Disclaimer: The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-1748.Corresponding Author: Demetre Daskalakis, MD, MPH, 1600 Clifton Rd NE, Mailstop US8-5, Atlanta, GA 30333; e-mail, [email protected]gov.Author Contributions: Conception and design: D. Daskalakis, J. Mermin.Analysis and interpretation of the data: J. Mermin.Drafting of the article: D. Daskalakis, L. Mena, J. Mermin.Critical revision for important intellectual content: D. Daskalakis, R.P. McClung, L. Mena, J. Mermin.Final approval of the article: D. Daskalakis, R.P. McClung, L. Mena, J. Mermin.This article was published at Annals.org on 16 June 2022.* For a list of the members of the Centers for Disease Control and Prevention's Monkeypox Response Team, see the Appendix. PreviousarticleNextarticle Advertisement Annals Author Insight Video - Demetre Daskalakis, MD, MPH In this video, Demetre Daskalakis, MD, MPH, offers additional insight into the article, "Avoiding the Mistakes of Past Infectious Disease Epidemics." 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